System changes improve prenatal care for Medicaid beneficiaries

CORVALLIS, Ore. – Oregon's 2012 shift to an incentivized, accountable-care system for Medicaid beneficiaries led to positive changes for expectant mothers and their babies, research at Oregon State University shows.

The research found Oregon's implementation of "coordinated care organizations" resulted in more expectant moms starting prenatal care on time. It also showed a small narrowing of the gap in prenatal care quality between Medicaid beneficiaries and those with private insurance.

Late-starting or inadequate prenatal care is connected to a number of adverse outcomes, including low birth weight, preterm birth, stillbirth and infant death.

"Improving women's access to adequate prenatal care — typically defined as initiating prenatal care within the first trimester of pregnancy and adhering to recommended prenatal care visits — can facilitate the identification and subsequent management of high-risk pregnancies," said Ifeoma Muoto, who was a doctoral student working with Associate Professor Jeff Luck in OSU's College of Public Health and Human Sciences at the time of the study.

Muoto, now an administrative fellow at Kaiser Permanente Southern California, looked at more than a half-million pregnancies in a six-year period in Oregon and Washington, including 2013, the first year for Oregon's 16 coordinated care organizations, or CCOs. Washington served as the control group.

The study's objective was to assess the impact of the CCOs on the quality of prenatal care among Oregon Medicaid beneficiaries. The results were recently published in the journal Health Affairs.

The study also showed a narrowing, albeit a small one, of the gap in prenatal care quality between Medicaid beneficiaries and those with private insurance.

"Prenatal care was one of the performance measures for the new CCOs and you can't disentangle the measures from the CCO startup, but it's promising that just in the first year there were significant improvements," Luck said.

Luck is a member of the Oregon Health Authority's Metrics and Scoring Committee, which is charged with determining whether CCOs are "effectively and adequately improving care, making quality care accessible, eliminating health disparities, and controlling costs."

The committee picked which types of care would be incentivized – meaning which types of care would serve as benchmarks that CCOs could meet to earn more funding. Other types of care that are incentivized include chronic diseases, substance abuse and mental health.

"We hypothesized that the CCOs would have the benefit for prenatal care that they did," Luck said. "This is early evidence that some of the care delivery improvements we hoped for really are occurring."

The federal Office of Disease Prevention and Health Promotion's HealthyPeople 2020 initiative includes increasing the percentage of women who initiate prenatal care in the first trimester of pregnancy from 70.8 percent to 77.9 percent.

In Oregon, the rate of pregnant Medicaid beneficiaries starting care in the first trimester climbed from 73.1 percent in the pre-CCO period to 77.3 percent in the first year of the CCOs. In Washington, the rate for women on Medicaid rose from 71.7 to 73.6 percent, a smaller percentage increase than Oregon's. Although women covered by private insurance in Oregon had higher levels of timely prenatal care initiation and prenatal care adequacy, the rates among that group were stable during the time period studied.

For prenatal care adequacy – initiating care in the first trimester and having at least nine doctor visits during a pregnancy – there was an increase from 65.9 to 70.5 percent for Medicaid-covered women in Oregon. That increase, though, was not statistically significant relative to the increase observed among Medicaid-covered women in Washington, where the improvement was 58.5 to 62.2 percent.

Luck noted the results indicated care adequacy was "going in the right direction but wasn't yet statistically significant."

"It's possible when we have more years of data we'll be able to make a more precise estimate," he said. "We also have a parallel project funded by the Centers for Disease Control using a larger pool of data from Oregon – not only birth certificates but Medicaid claims data, claims data from the Oregon Health Plan, which is Oregon's Medicaid program, and hospital discharge data."

Luck noted the research is particularly important given the percentage of births to Medicaid beneficiaries. Medicaid births made up roughly 45 percent of total U.S. births even prior to an expansion of the Medicaid program that began in January 2014.